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Transcript of Anaemia
NUTRITIONAL ANAEMIA Bachelor of Medicine and Bachelor of Surgery (MBBS220)
Haemopoietic and Lymphopoietic system
27 Dec 2013
Faculty of Medicine, Sg Buloh UiTM
Col Dr Amir Muhriz Abdul Latiff
Senior Lecturer and Haematologist Iron deficiency anaemia MEGALOBLASTIC ANAEMIA Prepared by:
Col (Dr) Amir Muhriz Abdul Latiff M.D (USM) Mpath (Haematology)
Senior Lecturer and Haematologist
Medical Faculty UiTM Define anaemia
Classify anaemia according to pathological mechanisms
Discuss the causes, effects, morphological changes and complications in iron deficiency anaemia.
Discuss the causes, effects, morphological changes and complications in megaloblastic anaemia.
Enumerate the lab investigations and scientific basis of the abnormalities seen in lab results. LEARNING OBJECTIVES PREAMBLE . www.who.int/topics/anaemia/en/ DEFINITION PRIMARY SIGN
Pallor on the conjunctiva and mucous membranes.
PRIMARY LAB RESULT
Adult male: Hb <13.5 g/dl
Adult female: Hb < 11.5 g/dl. Clinical signs and laboratory parameters Picture of conjunctiva and hands A haematology analyser Example of a read-out from a haematology analyser The Haematology analyser which is abnormal is usually flagged. The understanding of iron metabolism is important. Fig 1 Dietary iron
Ferritin Iron Metabolism Iron metabolism: Normal iron content of circulating haemoglobin and macrophages is indicated, as well as the approximate amount of iron absorbed and lost from the body each day. IRON METABOLISM Note: the size and colour of red cells relative to each other. DEFINITION
ROLE OF B12, FOLATE IN HUMAN PHYSIOLOGY
CAUSES OF MEGALOBLASTIC ANAEMIA
SUMMARY LEARNING OBJECTIVES A Group of disorders characterised by a macrocytic blood picture and megaloblastic erythropoiesis. DEFINITION ROLE OF B12, FOLATE IN DNA BIOSYNTHESIS Megaloblastic anemia: absorption of B12. IF, intrinsic factor; R, R-binder; TcI, transcobalamin I; TclI, transcobalamin II. GENERAL CAUSES
VITAMIN B12 DEFICIENCY
ABNORMALITIES OF VIT B12 METABOLISM
ABNORMALITIES OF DNA SYNTHESIS CAUSES Table 14.5 Robbins Pathologic basis of diseases 8th edition Causes of megaloblastic anaemia I
Vitamin B12 deficiency
Congenital IF deficiency
Partial or total gastrectomy
chronic tropical sprue
stagnant-loop syndrome (e.g., jejunal diverticulosis, ileocolic fistulae)
Ileal resection Table 14.5 Robbins Pathologic basis of diseases 8th edition Inadequate diet e.g. poverty
Drugs e.g. Anticonvulsants
Mixed e.g. Alcohol, Liver disease
Excess losses e.g dialysis
Malabsorption e.g. tropical sprue
Increased utilisation e.g. pregnancy,
malignancy, markedly increased haematopoiesis
Folic acid antagonists Folate deficiency
Decreased intake ATP, Adenosine triphosphate; CTP, cytosine triphosphate; d, deoxyribose; DHF, dihydrofolate; GTP, guanosine triphosphate; TDP, thymidine diphosphate; THF, tetrahydrofolate; TMP, thymidine monophosphate; TTP, thymidine triphosphate; UMP, uridine monophosphate. LAB FINDINGS Trademark cell: Oval macrocyte, (MCV > 100 fl)
Hypersegmented neutrophils - 98%
Pancytopenia, esp if anemia severe
Reticulocytopenia HAEMATOLOGICAL CHANGES IN MEGALOBLASTIC
ANAEMIA LDH elevated (90%)
Serum Fe normal or elevated
Serum B12 or folate low Biochemical changes in megaloblastic anaemia Bone marrow aspirate samples:Megaloblastic anemia. A, Low-power view of bone marrow fragments showing an increased cellularity with loss of fat spaces. B, Higher-power view of cell trails showing accumulation of early cells, an increased proportion of erythroid precursors, and the presence of giant metamyelocytes and hypersegmented neutrophils. Though hypercellular, the process of ineffective erythropoiesis hinders adequate production. Megaloblastic anaemia: typical lemon-yellow appearance of a 69-year-o1d woman with pernicious anaemia and severe megaloblastic anaemia (Hb, 7.0 g/dl; MCV, 132 fl). The colour is from the combination of pallor (from anaemia) and jaundice (from ineffective erythropoiesis). CLINICAL MANIFESTATIONS Megaloblastic anemia: spontaneous bruising on the thigh of a 34-year-old woman with widespread purpura and menorrhagia. She was found to have megaloblastic anemia as a result of nutritional folate deficiency and alcoholism. (Hb, 8.1 g/dl; MCV, 115 fl; platelet count, 2 × 109/L.) A and B, Marked vitiligo in a 67-year-old man. Pernicious anemia: sections of stomach. A, Normal; B, in pernicious anemia. There is atrophy of all coats, loss of gastric glands and parietal cells, and infiltration of the lamina propria by lymphocytes and plasma cells.
(A and B, Courtesy of Dr. J. E. McLaughlin.) Barium meal radiograph showing gastric atrophy and carcinoma. There is thinning of the gastric wall and lack of mucosal pattern and an ulcerated filling defect in the horizontal part of the greater curve. Bone marrow changes Biochemical changes Haematological changes clinical features Megaloblastic anemia: glossitis caused by B12 deficiency in a 55-year-old woman with untreated pernicious anemia. The tongue is beefy red and painful, particularly with hot and acidic foods. An identical appearance occurs in folate deficiency because of impaired DNA synthesis in the mucosal epithelium. Megaloblastic anemia: melanin pigmentation of the skin in a 24-year-old man with B12 deficiency caused by pernicious anemia. Similar pigmentation affected the nail beds, skin creases, and periorbital areas. Such pigmentation also occurs in patients with folate deficiency. In both, the pigmentation rapidly disappears with appropriate vitamin therapy. The biochemical basis for the melanin excess is unknown. Baby with spina bifida. Pernicious anaemia Pernicious anaemia Radiological abnormalities PERNICIOUS ANAEMIA Autoimmune destruction of parietal cells
Antibodies vs. parietal cells, intrinsic factor
Achlorhydria is universal
Increased incidence of gastric cancer
Increased incidence American blacks, northern Europeans
Often associated with other immune diseases
(eg Hashimoto's thyroiditis) This 38-year-old man shows premature graying and has blue eyes and vitiligo, three features that are more common in patients with pernicious anemia than in control subjects. ANAEMIA is a condition in which the number of red blood cells or their oxygen carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking and pregnancy status. Pernicious anemia: cross-section of spinal cord of a patient with severe B12 neuropathy who died (subacute combined degeneration of the spinal cord). There is demyelination of the lateral (pyramidal) and posterior columns (Weigert-Pal stain). Deficiencies in iron, folate or B12
Review clinical findings then lab investigations.
Hypochromic microcytic anaemia- Iron deficiency anaemia
Macrocytic anemia- Folate and B12 deficiency.
Always find out the cause of deficiency then treat the anaemia. NUTRITIONAL ANEMIAS
Summary CLINICAL AND LAB
FEATURES www.who.int/topics/anaemia/en/ ANAEMIA is a condition in which the number of red blood cells or their oxygen carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking and pregnancy status. DEFINITION OF ANAEMIA Picture of conjunctiva and hands Infants
Children < 5
Women of child bearing age GROUPS AT RISK OF IDA Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005. Increased demand for iron and/or haematopoiesis
Decreased iron intake or absorption Iron Deficiency—Aetiology Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005. Increased demand for iron and/or haematopoiesis
Decreased iron intake or absorption Iron Deficiency—Aetiology 1. Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.
Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005.
CDC. MMWR. 2002;51:899. Infancy and adolescence
Pregnancy and lactation
Low socioeconomic status and poverty greatly increase the prevalence of iron deficiency in this category of populations
In patients receiving erythropoietin therapy (= functional iron deficiency) Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005: Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005. In physiologic conditions
In pathologic conditions
Gastrointestinal tract pathology
In therapeutic procedures
In blood donation Iron loss Increased demand Reduced intake or reduced absorption CDC. MMWR. 1998;47(RR-3);1-36.
Annabale B, et al. Am J Med. 2001;111:439.
Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005. Vegetarians or malnutrition (low-cost diet)
Sprue, UHC, and Crohn’s disease
After gastric and intestinal surgery
Intestinal parasitosis (ankylostomiasis)
Helicobacter pylori infection
Autoimmune atrophic gastritis hypochromic microcytic red cells